S5377 Endoscopic-Guided Gastric Fundal Botulinum Injection for Intractable Hiccups Secondary to GERD and Esophagitis

Introduction: Hiccups are a common and typically benign, self-limited phenomenon. However, intractable hiccups – defined as lasting more than 1 month - can severely impair quality of life. We present a case of intractable hiccups refractory to standard medical and surgical management that improved following targeted gastric fundal botulinum toxin injection. Case Description: A 34-year-old man with a past medical history of long-standing gastroesophageal reflux disease (GERD) with esophagitis and gastritis presented with a 6-month history of hiccups. Hiccups severely impaired his quality of life, causing anorexia with an associated 25-pound weight loss and impaired his ability to work. The patient was counseled on dietary modification, physical maneuvers, and maximal proton pump inhibitor therapy, all without benefit. Extensive evaluation including CT chest and abdomen, endoscopy, and barium esophageal revealed an 8 cm hiatal hernia and LA Grade D esophagitis. Patient was also evaluated by pulmonology and neurology; both workups were unremarkable. The patient underwent robotic Dor fundoplication 2 months after presentation, without improvement. Patient was further trialed on baclofen, gabapentin, metoclopramide, and chlorpromazine; all had only offered transient symptom relief. The patient underwent endoscopic-guided botulinum toxin (100 units) injection to the gastric fundus and gastroesophageal junction to target the diaphragm. Throughout the perioperative period and preceding diagnostic esophagogastroduodenoscopy, the patient continued to experience frequent hiccups, which abruptly ceased 1 minute and 30 seconds after the first Botox injection. However, hiccups recurred after eight days. Repeat EGD with injection was repeated 1 month later with sustained significant improvement in clinical symptoms. At a follow-up visit 1 month later, he continued to report significant symptom relief. Discussion: Intractable hiccups are a rare but debilitating condition that can severely impact quality of life. GERD and esophagitis, especially in the setting of a hiatal hernia, are well known triggers due to irritation of the vagus or phrenic nerves. In patients with intractable hiccups refractory to standard medical therapy, endoscopic-guided injection of botulinum toxin targeting the diaphragm may offer an effective therapeutic option.